Urethrovaginal fistulae are generally secondary to
one of two conditions: (1) surgical trauma following anterior colporrhaphy
or (2) obstetrical trauma.

In many instances, a urethrovaginal fistula
exists, but the patient is still completely continent and has no problem
voiding. Some patients with this condition, especially those with the
fistula in the proximal one-third of the urethra, suffer a combination
of incontinence and inability to control their urine stream when attempting
to void. This technique is not applicable to fistulae in the distal
one-third of the urethra. Those fistulae are adequately treated by
the Spence operation.

Physiologic Changes. In repairing
a urethrovaginal fistula, the surgeon corrects the physiology of the
urethra so that the patient may remain continent and the urinary stream
may be emitted normally from the meatus. This procedure consists of
three basic principles: (1) excise the scarred, devascularized tissue
surrounding the fistula, (2) approximate healthy margins of tissue
with multiple layers of closure, and (3) bring a source of blood supply
and support to the base of the urethra to cover the fistula. This is
particularly important in those cases where severe scarring and devasularization
of tissue have occurred.

Preoperative evaluation of the patient should
consist of a complete bladder-urethra workup including urodynamics,
cystoscopy, urethroscopy, and urine culture.

Points of Caution. The margins of
the fistula must be brought together without tension. The flaps of
the pubovesical cervical fascia must be mobilized to allow the double-breasted
closure technique. The size and caliber of the urethra must be adequate
for voiding. The multiple-layer approach to fistula closure has stood
the test of time and represents the best opportunity for permanent
closure.

A vascular pedicle flap such as the bulbocavernosus
muscle has reduced the incidence of recurrent fistula in high-risk
patients.

Technique

With the patient in the dorsal lithotomy
position, the fistula in the proximal third of the urethra is
demonstrated. The vaginal mucosa is incised from the urethral
meatus past the fistula site.

The pubovesical cervical fascia
flaps are mobilized on each side. After complete mobilization
of these flaps, the urethral mucosa of the fistula is closed
with a running 4-0 monofilament synthetic absorbable suture.
After closure of the urethral mucosa, the pubovesical cervical
fascia flap on the patient's right is closed to the base of the
pubovesical cervical fascia on the left with interrupted 3-0
monofilament delayed synthetic absorbable suture.

The pubovesical cervical fascia
flap from the patient's left is closed in double-breasted fashion
over the flap of pubovesical cervical fascia from the right.
This closure is completed with 3-0 monofilament delayed synthetic
absorbable suture.

If the fistula has been previously
operated on or if there are factors such as radiation, a vascular
flap should be brought over the suture line of the double-breasted
pubovesical cervical fascia. The bulbocavernosus flap is initiated
by an incision in the labia majora. The bulbocavernosus muscle
with its associated fat pad is mobilized.

The muscle is transected posteriorly;
its blood supply comes from the vessels of the mons pubis. A
Kelly clamp has been inserted on top of the pubovesical cervical
fascia under the vaginal mucosal and enters the wound from the
bed of the bulbocavernosus muscle.

The bulbocavernosus flap is pulled
through the defect created by tunneling under the vaginal mucosa,
the labia minora, and the labia majora.

The bulbocavernosus flap is sutured over
the urethrovaginal fistula repair with the double-breasted closure
of the pubovesical cervical fascia.

The skin over the labia majora is closed
with interrupted monofilament synthetic absorbable suture. The
vaginal mucosa is shown closed with interrupted synthetic absorbable
suture. Ghosted under the closure of the vaginal mucosa is the
bulbocavernosus flap.

A suprapubic Foley catheter
should be inserted for 1 week to allow urethral mucosal healing
before spontaneous voiding.